Sternoclavicular joint reconstruction with gracilis autograft may be used for instability
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The sternoclavicular joint has high native stability, with static stabilization provided by the joint capsule, costoclavicular and interclavicular ligaments.
Dislocations of the sternoclavicular joint are rare, representing 3% of injuries to the shoulder girdle and 1% of all dislocations. Most dislocations are traumatic in nature, though a minority of patients present with spontaneous or atraumatic subluxation or dislocation. While instability can occur in both the anterior and posterior planes, posterior dislocation is less frequent, with a reported incidence between 5% to 27%. This is likely heavily influenced by the strength of the posterior capsule, which was found in a biomechanical study to require a 50% greater force to posteriorly displace the sternoclavicular joint than in any other direction.
Source: Amelia Drumm, BA
Posterior sternoclavicular dislocations need immediate surgical attention due to potential compromise of the mediastinal structures, whereas anterior dislocations can undergo nonoperative treatment initially, with good outcomes reported, especially in case of atraumatic onset. Some patients progress to chronic instability, and some are left with persistent pain and impairment of shoulder function. In these patients, surgical reconstruction of the sternoclavicular joint is a viable treatment option for recalcitrant symptomatic instability and/or pain. Multiple techniques are available for reconstruction of the sternoclavicular joint, although biomechanical evidence supports the figure-of-eight technique as the most stable reconstruction with good clinical outcomes also being reported.
Technique
Preoperatively, the patient is carefully evaluated to ensure that recurrent anterior instability is the correct diagnosis. In addition to plain radiographs, the senior author prefers to also obtain MRI or a computed angiogram to assess the relationship between the sternoclavicular joint and the juxtaposed major mediastinal vessels. A thoracotomy tray and thoracic surgeon are typically readily available during the case, and two large, bore IV lines are placed. After induction of general anesthesia, the patient is placed supine in 30° of reverse Trendelenburg. Mobility and reducibility of the sternoclavicular joint are assessed to confirm hypermobility. A hamstring autograft (gracilis tendon) is harvested from the knee by the standard technique. This is typically 3.5 mm in diameter. Both ends of the autograft are whip-stitched with nonabsorbable high-strength sutures (FiberWire #2; Arthrex) and measured to determine the appropriate drill tunnel diameter (typically 3.5 mm to 4 mm).
A 10-cm to 12-cm incision is made over the medial third of the clavicle to ensure adequate exposure of the medial clavicle and sternoclavicular joint. The sternocleidomastoid tendon, which typically courses directly over the sternoclavicular joint, is elevated and protected. The medial clavicle undergoes subperiosteal dissection circumferentially around the medial clavicle from the sternoclavicular joint to 10 cm to 12 cm laterally. The sternoclavicular joint capsule is also released until the medial clavicle is completely free. It is important to preserve the costal attachment of the costoclavicular ligament for later repair. The sternoclavicular joint is then disarticulated, moving the clavicle superiorly to allow access to the retrosternal space. The intra-articular disc is then removed sharply. The medial clavicle is carefully retracted superiorly, and the retrosternal space is dissected. A periosteal elevator is positioned posterior to the sternum to protect the retrosternal structures and to avoid vascular injury. Two 4-mm bone tunnels are placed superiorly and inferiorly in the manubrium site, 1.5 cm apart and 1 cm to 2 cm away from the joint line. Each tunnel is drilled independently after placing a guide pin in the anterior-to-posterior direction using a cannulated drill, typically 0.5 mm larger than the diameter of the graft.
Next, a malleable retractor is placed posterior to the medial aspect of the clavicle for protection of the vascular structures. Again, two bone tunnels are drilled from anterior-to-posterior in the superior and inferior aspect of the medial clavicle with spacing comparable to the sternal tunnels. The tunnels are again drilled with cannulated drills, typically 4 mm, approximately 0.5-mm larger than the graft diameter. Passing sutures are placed in the bone tunnels, and the graft is shuttled through these in a figure-of-eight configuration with the parallel limbs posterior and cruciate limbs anterior. The free ends of the whip-stitched graft are knotted together. Multiple #2 permanent sutures and absorbable sutures are placed through the tendon knot to secure the construct (FiberWire #2; Arthrex).
The area surrounding the bone tunnels is injected with demineralized bone matrix to enhance tendon incorporation and to minimize the risk of tunnel widening. Lastly, the integrity of the construct is evaluated through manipulation of the medial clavicle with anterior and posterior directed force using a Kocher clamp. The arm is placed through passive range of motion to evaluate dynamic stability under direct visualization. The periosteum and capsule are then reefed with a pants-over-vest capsulorrhaphy to add additional stability. The important costoclavicular ligaments, which are located approximately 15-mm lateral the medial end of the clavicle, should be incorporated into the capsular repair as these add additional strength to the construct. The overlying muscles are then meticulously repaired, and the skin closed.
Discussion
The surgical technique described for sternoclavicular joint reconstruction using a gracilis tendon autograft is biomechanically optimized and clinically proven. This article provides important technical pearls to perform a safe reconstruction of the joint that has been shown to have both biomechanical and clinical advantages compared with other variations of the surgical intervention. The proximity of the joint to vital mediastinal structures, in addition to the inherent complexity of this diarthrodial joint that connects the upper extremity to the axial skeleton, makes this a technically challenging procedure. Meticulous care is applied to preserve these structures and their function. This includes subperiosteal dissection and subsequent repair of the costoclavicular ligament and avoidance of clavicular resection to minimize risk of recurrent instability due to insufficiency of the costoclavicular ligaments. Tunnels are drilled in a straight fashion with sufficient bone bridges to minimize the risk of iatrogenic fracture.
Great effort is taken to prioritize patient safety throughout the procedure. A thoracic surgeon is notified to be made available during the case, a thoracotomy tray is in the room and two large, bore IV lines are placed prior to the start of the surgery. Meticulous capsular release with subperiosteal dissection is performed to fully mobilize the medial clavicle and allow for adequate access to retrosternal space. Attention is consistently focused on protection of the subclavian vessels and retrosternal vascular structures. Lastly, all drilling is performed with protective retractors posterior to the sternum and posterior to the medial clavicle with use of the punctilious technique to avoid overpenetration.
There are numerous reasons why this graft choice and reconstruction technique are favored at our institution and produce excellent clinical and functional results. The figure-of-eight method is the most biomechanically stable configuration with a load to failure nearly three times greater than other configurations studied. The technique rebuilds the primary and secondary stabilizers of the joint without significantly altering the biomechanics of the joint. This allows the joint to have the mobility necessary for proper glenohumeral function. The autologous gracilis hamstring tendon has both sufficient length and cross-sectional diameter to create the figure-of-eight technique. It also has the additional benefits of an autograft, which includes better biologic tissue integration during healing, without the risk of immune-mediated tunnel widening. Furthermore, it avoids the use of pins or wires that earlier reconstruction techniques required, as these were associated with detrimental migration of hardware, ultimately optimizing patient safety.
Clinically, there have been multiple studies indicating that the figure-of-eight reconstruction with a free graft is superior to repair or reconstruction with local tissue. In the past decade, we have published several case series and outcome studies on this technique utilizing autologous hamstring grafts, specifically. In 2016, Maximilian Petri, MD, and colleagues published a short-term outcome study on 21 sternoclavicular joint reconstructions that demonstrated significantly improved pain and function scores. Mean patient satisfaction was 8.5 out of 10 at short-term follow-up. In the largest series to date, Lucca Lacheta, MD, and colleagues from our group found that, at a minimum 5-year follow-up, pain scores, stability and functional outcomes improved significantly postoperatively. There was a low revision rate and notably 94% of patients returned to sport, including one patient who was preoperatively incapable due to sternoclavicular joint pain.
Conclusion
Sternoclavicular joint reconstruction using a gracilis hamstring autograft in a figure-of-eight orientation is a viable treatment option for patients experiencing pain and recurrent sternoclavicular joint instability.
Reconstruction of the sternoclavicular joint is associated with significant improvements in pain and functional outcomes, with low rates of recurrent instability and revision reported at midterm follow-up. Nonetheless, it is a rare and technically difficult surgery and, therefore, must be performed by a skilled orthopedic surgeon with experience in this procedure.
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- For more information:
- Amelia Drumm, BA; Maximilian Hinz, MD; and Peter J. Millett, MD, MSc, can be reached at The Steadman Clinic and Steadman Philippon Research Institute in Vail, Colorado. Millett’s email: drmillett@thesteadmanclinic.com.
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